In NSW, work on systems responding to the deterioration of patient within acute care settings started in the 1980s, with the work done by Prof Ken Hillman, an intensivist at Liverpool Hospital in south-western Sydney. This gave rise to the Medical Emergency Team (MET), an intensive care unit-based team that would respond to calls within the hospital, based on deterioration beyond pre-determined thresholds known as the MET criteria.

Despite the compelling logic of the system, the implementation and uptake of MET throughout NSW Health was patchy, with gradual adoption over the decades that followed. Such systems locally and internationally are now more commonly referred to as rapid response systems.

In 2006, the Greater Metropolitan Clinical Taskforce (GMCT) commissioned and published a report by two intensive care physicians, Dr Don Harrison and Dr Theresa Jacques. Based on evidence derived from the NSW Patient Safety and Clinical Quality program incident reporting system, it identified that, in keeping with other health systems world-wide, unrecognised patient deterioration, without an adequate response, was relatively common in the NSW public health system. Following the report and based on recommendations within it, the CEC investigated strategies to improve the recognition and response system in NSW. The document Between the Flags: The Way Forward summarised the CEC findings and became the foundation for subsequent design and implantation of the Between the Flags (BTF) program.

In November 2008, a Commission of Inquiry (The Garling Inquiry) reported to the NSW Government on Acute Care Services in NSW Public Hospitals. It was triggered by the death of Vanessa Anderson, a 16-year-old girl who died a preventable death, because her deterioration was not detected in one of the State's major teaching hospitals. The inquiry came amongst a background of increasing public concern and media coverage about quality and safety issues in the NSW public health system.

It identified a number of important problems within the system and made 139 wide-ranging recommendations for improvement. Recommendation 91 was that the CEC's Between the Flags project be implemented in all hospitals in NSW as follows.

Within 12 months, NSW Health is to implement a system in accordance with the recommendations of the Clinical Excellence Commission for the detention [sic] of deteriorating patients containing the following elements:

  • a system for early identification of an at-risk patient in every hospital in NSW (this system will involve the implementation of a specifically designed vital signs/observation chart);
  • escalation protocols to manage deteriorating patients, which would include a rapid response system;
  • development and implementation of detailed education and training programs, aimed at recognising and managing the deteriorating patient;
  • the ongoing collection and analysis of appropriate data to monitor the implementation and progress of the program;
  • a standardised process for the handover of patients which can be utilised on all occasions and can equally be done when all clinicians are not on site together;
  • high level support from management and clinicians; and
  • ongoing evaluation

Recommendation 91 had a high political profile and short time frames for implementation, with the CEC given responsibility specifically to implement a system for detecting deteriorating patients. The program's design included a multivalent strategy, where five elements would act synergistically in achieving the overall goal. They included:

  • Governance
  • Standard Calling Criteria
  • Clinical Emergency Response Systems
  • Education
  • Evaluation

Through extensive consultation, and planning, BTF started being implemented in NSW public health facilities in January 2010. At this time, each facility was required to implement the Standard Adult General Observation Chart (SAGO) and its Clinical Emergency Response System (CERS). The education program, titled DETECT, which provides education to all levels of staff within NSW Health, started in 2010.

Due to variance required for specific patient groups, charts were specially developed for paediatrics, emergency, and maternity, with implementation of these tools staged as follows:

  • Children (paediatric) - January 2011
  • Maternity patients - December 2011
  • Emergency department patients (adults and children) - from November 2012.

Education for staff in the paediatric field was developed and titled DETECT junior. Education for maternity staff was integrated into the pre-existing FONT training.

Work is continuing with other patient groups, to design specific BTF observation charts and on the transition of service from a paper-based model to the electronic observation charts.